Read the case notes below and complete the writing task which follows.

Notes:

Hospital: Flinders Medical Centre

Patient Details:

Admission date: 22/10/08

Discharge date: 26/10/08

Diagnosis: Carbon monoxide poisoning- home kerosene heater Past

Social History /Supports:Retired bank employee- Commonwealth Bank Lives with wife and adopted daughter- both overseas at present

Day 1- 22/10/08/ On examination: widely dilated pupils Unconscious Cold clammy skin, cherry red lips and skin Dyspnoea Physical examination. Assessed for head injury or other Precipitating factors causing coma- negative result. Blood test for blood sugar to ? diabetic coma- negative result.

Treatment: 0₂ Sats at 98% on 2 L/min via nasal specs Hyperbaric oxygenation Hourly assessment of vital signs Calm environment NG tube inserted for feeding Monitored for asphyxia Registrar visit 2pm Knees flexed using pillows Foot board to prevent foot drop Pressure Area Care: frequent change in position and back rub In- dwelling catheter Skin care for psoriasis

Observation:Patient comatose, but no other physical injuries. No asphyxia

Day 2- 23/10/08 Treatment:0₂ Sats at 98% on 2 L/min via nasal specs Hyperbaric oxygenation ceased at 1900 Hourly assessment of vital signs Calm environment NG tube Skin specialist assessment re psoriasis Skin care for psoriasis Foot board to prevent foot drop Pressure Area Care: frequent change in position and back rub. Skin intact IDC draining moderate amounts

Observation:Patient regained consciousness with right hemi-plegia 1800

Day 3- 24/10/08 Treatment: Assessment for consciousness GCS 14 but varies Hourly assessment of vital signs Calm environment Good ventilation NG tube removed- liquid diet per oral Mobility assessment Right sided weakness Speech affected, vision as per normal for this patient Small pillow placed on affected right side for prevention of adduction of arm Physiotherapist assessment and commencement of passive exercises Pressure Area Care: frequent change in position and back rub Removal of IDC

Observation:Level of consciousness with right-sided weakness. Comfortable, depressed and anxious re prognosis

Days 4- 25/10/08 Treatment:Assessment for conscious GCS 15 2 Hourly assessment of vital signs Physiotherapist visit- passive exercise continued Range of motion gradually increased Pressure Area Care: patient encouraged to move off sacrum as it is a little red Full ward diet and fluids

Observation:Patient mentally stable, but depressed. Making steady physical progress. Doctor has advised discharged tomorrow and further rehabilitation at The General Repatriation Hospital

Nursing Management: Provided comfortable stable environment Output, skin integrity, diet monitored Assistance in regaining physical health.

Discharge plans:Daily assessment and support from physiotherapist and possibly occupational therapist for increased mobility and physical ability Psychiatrist visits to be initiated regarding depression caused by loss of mobility and independence following the accident

Writing Task:Write a letter of referral to the Director, General Repatriation Hospital, Daw Park, using the information above.

In your answer:Expand the relevant case notes into complete sentences Do not use note form Use letter format. The body of the letter should be approximately 180-200 words.

View sample answer by Lifestyle Training Centre

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